Event Notification Report for July 02, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/01/2008 - 07/02/2008
Hospital
Event Number: 44333
Rep Org: HELEN NEWBERRY JOY HOSPITAL
Licensee: HELEN NEWBERRY JOY HOSPITAL
Region: 3
City: NEWBERRY State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: CHAD BRUNO
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: HELEN NEWBERRY JOY HOSPITAL
Region: 3
City: NEWBERRY State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: CHAD BRUNO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/02/2008
Notification Time: 16:40 [ET]
Event Date: 07/02/2008
Event Time: 15:00 [EDT]
Last Update Date: 07/03/2008
Notification Time: 16:40 [ET]
Event Date: 07/02/2008
Event Time: 15:00 [EDT]
Last Update Date: 07/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
10 CFR Section:
20.1906(d)(1) - SURFACE CONTAM LEVELS > LIMITS
Person (Organization):
RONALD BELLAMY (R1)
THOMAS KOZAK (R3)
ANDREW PERSINKO (FSME)
RONALD BELLAMY (R1)
THOMAS KOZAK (R3)
ANDREW PERSINKO (FSME)
MOLYBDENUM-99 PACKAGE WITH EXTERNAL CONTAMINATION
A nuclear medicine technologist from Helen Newberry Joy Hospital reported receiving a package containing a Molybdenum-99 generator (148 GBq) that had an external radiation of 30 mR/hr and 23,985 dpm (with a background of 11695 dpm). The external contamination was removable using a wipe test. The Molybdenum generator will not be used until next Tuesday and will be stored in a room requiring entry through three locked doors. The Nuclear Technologist will be informing the package carrier of the contamination. He was uncertain where the packaged originated or who the licensed shipper of the package was at the time of the report but would attempt to determine the information and contact the responsible party.
* * * UPDATE BY HUFFMAN AT 0930 EDT ON 7/3/08 * * *
Thi event was updated to make some minor editorial corrections and clarifications.
A nuclear medicine technologist from Helen Newberry Joy Hospital reported receiving a package containing a Molybdenum-99 generator (148 GBq) that had an external radiation of 30 mR/hr and 23,985 dpm (with a background of 11695 dpm). The external contamination was removable using a wipe test. The Molybdenum generator will not be used until next Tuesday and will be stored in a room requiring entry through three locked doors. The Nuclear Technologist will be informing the package carrier of the contamination. He was uncertain where the packaged originated or who the licensed shipper of the package was at the time of the report but would attempt to determine the information and contact the responsible party.
* * * UPDATE BY HUFFMAN AT 0930 EDT ON 7/3/08 * * *
Thi event was updated to make some minor editorial corrections and clarifications.
General Information or Other
Event Number: 44335
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: BAYLOR MEDICAL CENTER
Region: 4
City: WACO State: TX
County:
License #: L01290
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: BAYLOR MEDICAL CENTER
Region: 4
City: WACO State: TX
County:
License #: L01290
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/03/2008
Notification Time: 14:11 [ET]
Event Date: 07/02/2008
Event Time: 12:04 [CDT]
Last Update Date: 07/03/2008
Notification Time: 14:11 [ET]
Event Date: 07/02/2008
Event Time: 12:04 [CDT]
Last Update Date: 07/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RUSS BYWATER (R4)
ANDREW PERSINKO (FSME)
RUSS BYWATER (R4)
ANDREW PERSINKO (FSME)
AGREEMENT STATE REPORT - LESS THAN 10% OF PRESCRIBED DOSE DELIVERED
"A medical event occurred at 12:04 pm on July 2, 2008. The licensee is Baylor University Medical Center, License Number L01290.
"The unsealed source is Y-90 Therasphere microspheres for treatment of liver cancer. The prescribed dose is 100 Gray, and the prescribed dose range is from 95 Gray to 105 Gray.
"The activity of the Y-90 Therasphere microspheres was verified at 9:13 am - with 13.4 mCi in the vial - using the dose calibrator as per the manufacturer instructions. However when the dose was delivered the 3 way stop-cock was set erroneously and almost the entire dose was collected in the vent vial. Attempts to recover and deliver the misdirected dose was very limited. Post-administration, the residual activity in the original dose vial, the vent vial, and contaminated effects (catheter line, tubing, needles, towels, gauze pads, etc) totaled 12.046 mCi normalized to the 9:13 am verification time. Therefore, the estimated administered activity was approximately 1.3 mCi, administered on 2-July-2008 at 12:04 pm. This translates to approximately 8.7 Gray delivered to the treatment site (Liver Tumor).
"Essentially only 8.7% of the prescribed dose was delivered. The licensee is continuing the investigation."
Texas event report I-8522
A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
"A medical event occurred at 12:04 pm on July 2, 2008. The licensee is Baylor University Medical Center, License Number L01290.
"The unsealed source is Y-90 Therasphere microspheres for treatment of liver cancer. The prescribed dose is 100 Gray, and the prescribed dose range is from 95 Gray to 105 Gray.
"The activity of the Y-90 Therasphere microspheres was verified at 9:13 am - with 13.4 mCi in the vial - using the dose calibrator as per the manufacturer instructions. However when the dose was delivered the 3 way stop-cock was set erroneously and almost the entire dose was collected in the vent vial. Attempts to recover and deliver the misdirected dose was very limited. Post-administration, the residual activity in the original dose vial, the vent vial, and contaminated effects (catheter line, tubing, needles, towels, gauze pads, etc) totaled 12.046 mCi normalized to the 9:13 am verification time. Therefore, the estimated administered activity was approximately 1.3 mCi, administered on 2-July-2008 at 12:04 pm. This translates to approximately 8.7 Gray delivered to the treatment site (Liver Tumor).
"Essentially only 8.7% of the prescribed dose was delivered. The licensee is continuing the investigation."
Texas event report I-8522
A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.